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Imaging Findings in Neonatal and Pediatric Posterior Reversible Encephalopathy Syndrome (PRES) Differ From Adults
Charlene Pringle1, Katherin Portwood2, Manuel A Viamonte3
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida.
Insights
Pediatric Posterior Reversible Encephalopathy Syndrome (PRES) often presents with atypical MRI findings, differing from adult patterns. While acute edema resolves, follow-up imaging may reveal persistent changes, even in infants.
Area of Science:
- Pediatric Neurology
- Neuroradiology
- Neuroscience
Background:
- Posterior Reversible Encephalopathy Syndrome (PRES) is a clinical-radiographic syndrome typically characterized by reversible posterior leukoencephalopathy on neuroimaging.
- Adult MRI findings in PRES classically show reversible parietal-occipital disease.
Purpose of the Study:
- To investigate the neuroimaging distribution of PRES in a pediatric cohort.
- To determine if atypical MRI findings are common in children with PRES.
- To assess the evolution of PRES findings on follow-up imaging in children.
Main Methods:
- Retrospective review of pediatric patients diagnosed with PRES between 2010 and 2018.
- Analysis of MRI scans at diagnosis and follow-up by a pediatric radiologist.
- Correlation of imaging findings with clinical presentation.
Main Results:
- Out of 19 pediatric patients (0-18 years), 84% exhibited atypical MRI findings.
- Widespread anatomical distribution was observed, including frontal lobe involvement in 63%.
- Follow-up imaging in 63% of patients revealed persistent abnormalities, including volume loss.
Conclusions:
- Pediatric PRES MRI findings frequently deviate from the classic adult posterior distribution.
- Acute vasogenic edema typically resolves, but volume loss may persist on follow-up.
- PRES is increasingly identified in infants, expanding the age range for this condition.
Background:
Posterior reversible encephalopathy syndrome (PRES) is classically a reversible clinical radiographic syndrome associated with predominantly posterior leukoencephalopathy on neuroimaging. Magnetic resonance imaging (MRI) in adults demonstrates almost universally reversible parietal-occipital disease. We aimed to demonstrate in a cohort of children that "atypical" distribution is expected, acutely and on follow-up.
Methods:
A retrospective review of children diagnosed with PRES from 2010 to 2018 at our children's hospital was performed. All had MRI at diagnoses, with over half having follow-up MRIs. Images were reviewed by a neuroradiology-trained pediatric radiologist for confirmation of findings consistent with PRES/identification of involved regions.
Results:
Nineteen patients (aged zero to 18 years, 53% female) were included. Notably, two were infants. Nearly all had seizures; all had altered mental status and hypertension. Fifteen (84%) had MRI described as "atypical." Distribution of MRI findings was anatomically widespread, including nine with frontal findings. Twelve (63%) had follow-up imaging, of which approximately half remained abnormal.
Conclusions:
Pediatric PRES MRI findings were more often atypical at time of diagnosis. Vasogenic edema related to the acute phases of PRES typically resolved; however, follow-up imaging identified new volume loss in the areas affected. Two of our subjects were younger than 13 months, younger than typically described. Our series demonstrates that imaging distribution in children with PRES does not mirror the classical posterior, reversible distribution described in adults and continues the recent trend of identifying PRES in infants.
